1. Chapter 1
Overview of Coding

2. Introduction Coding systems: Starting a coding career
International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM)
Current Procedural Terminology (CPT)
Healthcare Common Procedure Coding System (HCPCS) level II
Starting a coding career

3. Coder
Acquire working knowledge of coding systems and rules, as well as payer requirements
Ensure coding accuracy
Communicate with providers about documentation and compliance issues, as well as assignment of codes

4. Training Formal course work Non-paid coding internship
e.g., medical terminology, anatomy, physiology
Non-paid coding internship
On-site at health care facility

5. Professional Associations Offering Coding Credentials
American Health Information Management Association (AHIMA)
American Academy of Professional Coders (AAPC)
American Medical Billing Association (AMBA)

6. Employment Opportunities
Clinics
Consulting firms
Government agencies
Hospitals
Insurance companies
Nursing facilities
Home health care agencies
Hospice organizations
Physician offices
Work at home

7. Benefits of Joining a Professional Association
Reduced membership fee
Many of the same benefits as active members
Eligibility for scholarships and grants
Networking opportunities
Publications
Reduced certification exam fees
Expanded website access

8. Professional Networking
Attend professional association conferences and meetings
Join online discussion boards (listservs)

9. Coding Overview
Facilities, providers, and third-party payers use coding systems and medical nomenclature to collect, store, and process data

10. Purpose of Coding Systems
Organize medical nomenclature
Vocabulary of clinical and medical terms
e.g., Systematized Nomenclature of Medicine (SNOMED)
Codes assigned for similar diseases and procedures
e.g., CPT, HCPCS level II, ICD-9-CM, ICD-10-CM, ICD-10-PCS

11. Codes Numeric and alphanumeric characters
Assigned to diagnoses, procedures, and services
Reported to payers and external agencies
Used internally for education, research, and statistical purposes

12. Health Insurance Portability and Accountability Act (HIPAA)
Portability and continuity of coverage
Fraud and abuse
Medical savings accounts
Access to long-term care services
Administration simplification
Electronic transactions
Privacy and security

13. Code Sets
Large
Encode diseases, causes of injury, disease prevention, equipment, and supplies
Small
Encode race, ethnicity, type of facility, and type of unit

14. Required Code Sets
HIPAA requires specific code sets to be adopted for use by clearinghouses, health plans, and providers (covered entities)
(continued)

15. Required Code Sets Code sets include the following: ICD-9-CM CPT
HCPCS level II
National codes
Current Dental Terminology (CDT)
National Drug Code (NDC)

16. Covered Entities Health care clearinghouses Health plans Providers
Not a third-party administrator (TPA)
TPA processes health care claims and performs related business functions for health plan
Health plans
Providers

17. Coding References Coding clinics
Conditions of Participation (CoP) and Conditions for Coverage (CfC)
CPT Assistant and HCPCS Assistant
National Correct Coding Initiative (NCCI) and Outpatient Code Editor (OCE) with Ambulatory Payment Classification (APC)
(continued)

18. Coding References Compliance program guidance documents
ICD-9-CM Official Guidelines for Coding and Reporting

19. Fraudulent Coding
Unbundling
Upcoding
Overcoding
Jamming
Downcoding

20. Documentation Issues
Health care providers responsible for documenting and authenticating patient records as legible, complete, and timely
Health care providers must properly correct or alter errors in patient record documentation

21. Patient Record Primary purposes: Serves as official business record
Documents services and treatment provided
Stores demographic data
Supports diagnoses
Justifies treatment
(continued)

22. Patient Record Primary purposes: Facilitates continuity of care
Serves as communication tool
Assists in planning individual patient care
(continued)

23. Patient Record Secondary purposes: Evaluates quality of patient care
Provides data for use in clinical research and epidemiology studies
Provides information to third-party payers for reimbursement of submitted claims
Serves medicolegal interests of patient, facility, and providers

24. Teaching Hospitals
Engaged in approved graduate medical education (GME) residency program
Residents involved in patient care
(continued)

25. Teaching Hospitals Patient record documentation includes:
Services furnished by residents
Participation of teaching physician in provision of services
Whether teaching physician was physically present when care was provided

26. Medical Necessity
Patient diagnosis must justify procedures or services provided
Providers document procedures, services, and supplies that are:
Needed for diagnosis and treatment
Performed to diagnose patient, direct patient care, and/or treat patient’s condition
(continued)

27. Medical Necessity
Providers document procedures, services, and supplies that are:
Consistent with standards of good medical practice in local area
Not performed primarily for convenience of physician or health care facility

28. If It Wasn’t Documented, It Wasn’t Done
Patient record serves as medicolegal document and facility’s business record
If provider performs service, but does not document it, payer can refuse to pay
Patient record is defense of quality of care administered to patient

29. Assumption Coding
Assignment of codes based on assumption that patient has certain diagnoses or has received certain procedures or services
Considered fraud
Note:
Implement physician query process to avoid fraud risks associated with assumption coding

30. Physician Query Process
Contact responsible physician
Query physician regarding documentation
Determine whether query will be generated concurrently or retrospectively
(continued)

31. Physician Query Process
Designate individual to serve as physician’s contact during process
Use query form to document query and physician’s response

32. Patient Record Formats
Manual
Source-oriented record (SOR)
Problem-oriented record (POR)
Automated
Electronic health record (EHR)
Optical disk imaging
(continued)

33. Patient Record Formats
Hybrid
Automated lab data reports and handwritten physician progress notes

34. Health Data Collection
Planning administrative tasks
Submitting statistics to state and federal government agencies
Reporting health claims data to third-party payers for reimbursement purposes

35. Reporting Data to Payers
Use of automated software
e.g., case abstracting software, medical management software
Data entered and imported into claims for submission
e.g., CMS-1500, UB-04
(continued)

36. Reporting Data to Payers
Reports generated for statistical analysis and reimbursement purposes

37. Sample Data Entry Screen
Permission to reuse granted by QuadraMed.

38. Verifying Codes
Coders responsible for reviewing patient records to select appropriate diagnosis and procedure or service
Claims can be denied if medical necessity of procedures or services not established